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No.
COMMONWULT14 Of MASSACHUSETTS
Board of Health,�49-t- O w,rr - , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTION PERMIT
Application for a Permit to Construct( ) Repair( ) Upgrade f/) Abandon()-Pomplete System ❑ Individual Components
Location 7 jv14d (,(i 00 W%%, to l�flm ,
Owner's Name
Map/Parcel# 31 Z/JV
Address / )E44 4 j e v rT S/ LI
dA dM ZVV
f
Lot#
Telephone# (.4- l 11
0a a d
Installer's Name C e s-e"Vam/mj Zoe,
Designer's Name f e
C
Address N
6 p
Address g d 3 Tt r �/;V , gy m /3 0,�6
Telephone# scb e-3 M-Wc ITOF w, /o/0
Telephone# zo
Type of Building
Dwelling - No. of Bedrooms
Other - Type of Building _
No. of persons
Lot Size sq. ft.
Garbage grinder( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s) _
Soil Evaluator Form No.
Name of Soil Evaluator
DESCRIPTION OF REPAIRS OR ALTERATIONS J -ee-
Date of Evaluation
Z, C,
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agrees to not to place the sys em in eration until a Certificate of ompliance has been issued by the Board of Health.
Signed Date 6 6
n k , _ L , , ii z _
No. ! -
_ v FEE i
COMMONWEALT14 OF MASSAC14USETTS d4 I :z s //,r
Board of Health, o t MA. /
CERTIFICATE OF COMPLIANCE
Description of Work: ❑ Individual Component(s)Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired (.Upgraded (i) -Abandoned ( )
by: lr rI T '. /j/ 4'2 , f (-.
at 7A
has been installed in accordance with the provisions o 310 CMR 15.00 (Title 5) and th approved design plans/as-built plans relating to
application No. _ `.�- dated 7— l` �. Approved Design Flow and
Installer `r `Y S jy I ' _
Designer. �; % #. kip f i Inspector: ii Date:
The issuance of this permit shall not be construed as a guarantee that the system will function as designed.
No. _ ( L" //BGG FEE
COMMONWEALTH Of MASSACHUSETTS
Board of Health, ) (6 (LM6 0714 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby granted to; Construct( ) Repair( ) Upgrade (;,.r Abandon( ) an individual sewage disposal system
at I',`.''. r - ,j I i - as described in the application for
}
Disposal System Construction Permit No. 2"_, dated 7
Provided: Construction shall be completed.withinAi�1df the date of this permit. All local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Charlestown. MA Date 7 // Board of Health